APPLICATION TO JOIN BRENTWOOD DAY NURSERY

Child’s Name: ………………………………………………………… Male ____ Female ____

Date of birth: ……..…………………………
Name(s) and addresses of parent(s) (both addresses of parents living separately): 

Name: 
Address:

Postcode:                       
Tel: 
Mobile:
Email:

Name: 
Address:

Postcode:                       
Tel:
Mobile:
Email:

We would like our child to start attending the nursery from………………………..(date) 
on the following days/sessions:
	Am
(8.30am-1pm)	Pm
(1pm-5.30pm)	School session (8.30am-3pm )	All day (8.30am-5.30pm)	
	1st choice	2nd choice	1st choice	2nd choice	1st choice	2nd choice	1st choice	2nd choice	
Monday									
Tuesday									
Wednesday									
Thursday									
Friday									
(Please tick required session/s and alternatives)

Please tick if your child is eligible for any of the following:
Free Early Years Entitlement for 3-4 years (term after 3rd birthday)
		
Approved Early Years Entitlement for 2 years (term after 2nd birthday)
		
Approved Extended 30 hours Entitlement for working parents 		
Special Provision Funding for children with Special Educational Needs and disabilities		

If we find that we no longer need the place, we will inform the setting as soon as possible.

Name & Signature of parent(s)
Mother/Carer                              Father/Carer  

Name in print:

Signature:

Name in print:

Signature: